What is a Brain Injury? Overview

By Lauren Costello | October 21, 2019 |

An acquired brain injury, or ABI, is an injury after birth that is not hereditary, degenerative, or induced by birth trauma. When the head is hit or the brain is damaged, how the brain functions and communicates with the rest of the body may become changed. ABI is used as the umbrella definition for brain injury and can be further defined by how the injury is sustained: traumatic and non-traumatic.

Different parts of the brain are responsible for different functions a person can perform, such as a person’s movements, emotions, processing of the sounds/sights around, starting or holding a conversation, or being able to pay attention or remember information.

When the brain is injured, tasks may be more challenging than prior to injury. Repetitive training and strategies to help compensate for change in function can form new pathways within the brain to facilitate rehabilitation.

Types of Brain Injury

Did you know that not all brain injuries are the same? Despite the make-up or changes in a person’s brain, people living with brain injury are people first – not a diagnosis or someone to be counted out. The type of injury refers to the method of injury, not necessarily the changes that can occur.

Non-traumatic Brain Injury

caused by changes occurring inside of the body that may lead to more localized or specific damage to the brain.

Examples:

stroke
substance overdose
lack of oxygen
brain tumors

Traumatic Brain Injury (TBI)

result of forces outside the body - a bump, jolt, or blow to the head - that may lead to more generalized effects (or damaging multiple areas of the brain).

Examples:

falls
motor vehicle collisions
assaults
blasts

Categories of TBI

Mild

Loss of consciousness lasting less than 30 minutes (or not at all), any alteration of consciousness, or no memory around the traumatic event (post-traumatic amnesia) lasting less than 24 hours. Glasgow Coma Scale score of 13 to 15.

Moderate & Severe

Loss of consciousness lasting more than 30 minutes to prolonged coma, post-traumatic amnesia lasting more than 24 hours (or permanently), and Glasgow Coma score as low as 3.

TBI By Numbers

Statistics

The United States

The CDC estimated that in 2013 2.8 million people sustained a TBI in the US.
- 50,000 die,
- 282,000 are hospitalized, and
- 5 million, nearly 90%, are treated and released from an emergency department (ED).
- An unknown number of individuals receive other medical care or no care. There is no estimate for the number of people with non-fatal TBI seen outside of an emergency department of a hospital or who receive no care at all.³
Direct medical costs and indirect costs of TBI, such as lost productivity, totaled an estimated $60 billion in the United States in 2000.⁴
Estimated Average Percentage of Annual TBI by External Cause in the United States³
- Falls – 47%
- Struck By/Against – 15%
- Motor Vehicle-Traffic – 14%
- Assault – 9%
- Unknown/Other – 15%

North Carolina:

During 2015, a TBI was sustained by 78,775 people in North Carolina alone or in combination with other injuries/conditions – according to ED, hospitalization, and death data.⁵
- 1,825 (18.7 per 100,000) died
- 7,062 (66.8 per 100,000), were hospitalized
- 69,729 (701.2 per 100,000) were treated and released from EDs
- An unknown number of individuals sustained injuries that were treated in other settings or went untreated.
Individuals 65 and older were the highest number of TBI-related deaths and ED visits, as well as most affected by hospitalizations.
Men were more likely to sustain a TBI than women, in correlation to the national population where men are 1.5 times more likely to sustain a TBI than women.

There are potentially many more individuals in North Carolina living with TBI-related long-term disability based on CDC state correlates. However, these numbers are likely an underestimate and a larger problem due to difficulty with data collection and the invisible nature of brain injury.

Over the span of six years (2007–2013), while rates of TBI-related ED visits increased by 47%, hospitalization rates decreased by 2.5% and death rates decreased by 5%.¹⁶ This can mean that more people are living with the effects of brain injury because of advances in medical care, training, and access to treatment. When a brain injury occurs, it can affect the individual, family, and entire community. Many individuals desire to engage in their community or with other in their environment to contribute or have a meaningful day. By coming together as advocates to provide an accepting and tolerant environment, the community as a whole can thrive.

Research & Special Populations

Military

TBI is the signature wound of the Iraq and Afghanistan wars with over 370,000 military service members worldwide identified with a TBI from 2000-2017. TBIs can occur in military service from a variety of sources including gunshots, blasts, motor-vehicle collisions, or training exercises. With NC having the third largest active duty population and over 770,000 veterans, many service members may need long-term care in North Carolina communities related to diagnosed or undiagnosed injuries. TBI can often be masked in military populations due to stigma or co-occurring mental health conditions.⁶

Sports- & Age-related

An estimated 1.6-3.8 million sports- and recreation-related concussions occur in the US each year with the most common injuries occurring from cycling, football, baseball/softball, and soccer. The actual incidence may potentially be much higher for those not treated or treated by their general doctor. The leading cause of TBI in the US is falls, with children 0-4 years of age and adults 75 years of age and older most at risk.⁷

Domestic Violence & Intimate Partner Assaults

TBI can be an unrecognized result of domestic violence and intimate partner assaults, commonly in women. The head and face are most commonly targets in these situations for TBI and individuals may experience an ABI if they lose oxygen to their brain caused by airway obstruction for too long of a time (caused by choking, strangulation, near drowning, or drug reaction/overdose). In one study, 67% of women at three metropolitan EDs reported problems potentially head-injury related with 30% experienced a loss of consciousness at least once. Multiple traumatic or acquired brain injuries can lead to cumulative cognitive, physical and emotional challenges over time and therefore make disengaging from the situation almost impossible due to decision-making and planning.^8,9

Individuals experiencing Homelessness or Economic Instability

TBI-related cognitive and behavioral challenges (e.g., limitations in memory; planning and organization; and reasoning, comprehension and problem solving, as well as impulsive decision-making) lead to an increased risk for economic and housing instability.¹⁰ Homeless individuals also are more vulnerable to common causes of TBI: Substance abuse related accidents (including falls) and victimization from violence. Thus, TBI-related cognitive and behavioral deficits not only increase risk for homelessness, but homelessness itself contributes to increased risk for TBI. On one night in January 2017, 8,962 people experienced homelessness in NC (be sure to take this number with a grain of salt as it is only a snapshot of a much larger population).¹¹ Meanwhile, in one study of 904 people, approximately half of those experiencing homelessness had sustained a TBI, of which 70% experienced their first brain injury before they experienced homelessness.¹² We do not know the true numbers of individuals that are experiencing homelessness in NC or the true number of people with TBI experiencing homelessness, but with increased access to community resources and screening the hope is that more people can be identified and their needs addressed.

Mental Health Experiences

Studies have indicated that those with positive TBI screens were more likely to have mental health disorders. The most common mental health disorders following a brain injury are schizophrenia, depression, bipolar disorder, and organic mental disorder. The nature of and whether mental health disorders or TBI have a direct causal effect on one another is heavily debated in research. In addition, diagnosis can be difficult due to the overlapping of signs and symptoms of concussion/mTBI and mental illness. For example, an individual with a TBI may experience agitation, impulsivity, poor-judgement that may mirror differences in attention deficit/hyperactivity disorder (ADHD). Flashbacks, hypervigilance, avoidance, nightmares could be attributed to TBI or to post-traumatic stress disorder (PTSD). An individual with depression may experience lack of motivation, sadness, and fatigue – so may a person with a TBI.^13,14 It is important when working with individuals with mental health conditions to consider TBI and similarly mental health to consider with TBI. Similarly, if you are living with TBI and experiencing mental health symptoms, connect with community resources including your doctor, a counselor, or neuropsychiatrist. Mental health after brain injury may be attributed to a variety of factors that either medication, alternative therapies, or community/social engagement can be helpful for

Substance Misuse

Similarly, to the overlapping symptoms between metal health and TBI, substance misuse and TBI interconnect as well.¹⁵ The relationship with substance misuse including alcohol and other drugs is a complicated and often bidirectional one. A large number of TBIs incur when individuals are intoxicated due to poor motor control, impaired decision making, vulnerability to victimization, and propensity toward belligerent/aggressive behaviors. Likewise, substance misuse following injury can increase the risk of sustaining additional TBIs, interfere with the brain’s recovery process after brain injury, have a more powerful effect after brain injury, and increase the risk of seizures after brain injury.¹ If you have an individual who has an identified TBI and is using substances, these are important factors to consider. If you are having trouble with substances, it can be helpful to seek professional consult as substance misuse can frequently affect mood, employment retention, social relationships, and community involvement. This can make it important to screen for TBI and ABI to assist in accessing appropriate services if you are a professional working with individuals who are misusing substances.

Changes after Brain Injury

PHYSICAL & SENSORY

(how your muscles or bodily health is affected)

seizures
fatigue & sleep disruption
headaches & pain
weakness or paralysis
movement & coordination
sexual function
balance
sensory changes (sight, smell, hearing, etc.)

THINKING & PROCESSING

(how you process and engage with your environment)

memory or recall
mental flexibility & learning
attention & concentration
initiation & motivation
task-switching & sequencing
mental fatigue
safety awareness & impulsivity
problem-solving & decisions
social skills & communication

EMOTIONS & BEHAVIOR

(how you feel & act that may be different than before)

difficulty with regulation (emotions or actions)
self-awareness
irritability or restlessness
unrelated laughter or crying
personality changes
lethargy or slowness
psychological conditions (depression, anxiety, etc.)

Science of TBI

Neurons are the communicating agents within the brain. All sensations, movements, thoughts, and feelings are a result of chemical signals (or neurotransmitters) produced between these cells. Neurons cannot communicate alone, however. Glial cells are like a warm blanket for the neurons, making neurons communicate at lightning speed. Recently scientists found out that glial cells are actually more in number than neurons in the brain. Therefore, if glial cells are affected through a brain injury, one’s processing speed may be compromised and neurons may not be nourished to thrive. Neurons and glial cells can be damage at the cellular level due to a lack of oxygen, excessive bleeding, swelling/pressure within the skull, or the tearing of neurons due to their long structure. The result can be chemical changes within the brain or functional changes affecting physical, cognitive, emotional, behavioral, and social capacities.

The brain is divided up into hemispheres and then lobes. Where the injury occurs within the brain can be reflective of the challenges and changes that occur afterwards. For example, the frontal lobe is responsible for concentration, planning, regulation, and organization. People after a frontal lobe injury may appear inattentive, have difficulty with initiation, or act impulsively. That is likely due to the connections that are affected within the brain.

Left Hemisphere

controls movement and sensation in the right side of the body
verbal and logical functions including language (listening, reading, speaking, and writing)
thought and memory involving words

Right Hemisphere

controls movement and sensation in the left side
nonverbal and intuitive functions such as putting bits of information together to make up an entire picture
recognizing oral and visual patterns and designs (music and art)
expressing and understanding emotions

Parts of the Brain

Frontal lobe	Organization & regulation (attention, processing, decision-making, initiation, etc.)
Parietal lobe	Integrating sensory information
Temporal lobe	memory, language, hearing
Occipital lobe	Visual processing
Brain Stem	Arousal, Breathing, Heart rate
Motor & sensory cortex	Movement and senses
Cerebellum	Coordination & balance
Limbic system	Fight or Flight, Reward Pathway, and Emotions

Just because a part of the brain may be injured, there is potential for physical and cognitive rehabilitation based on neuroplasticity – the brain’s capacity to change and adapt as the result of interactions with environment. This “re-wiring” of the brain can make it possible for an undamaged area to complete functions previously managed by a damaged area. For some, compensation strategies such as assistive technology, calendars, alarms, lists, and more can be helpful in completing daily tasks and helping with routines.

Strategies for Success

Many changes after a brain injury are not seen on the outside but can be all-consuming on the inside. Sometimes stigma or assumptions about people living with brain injury can affect independence or how someone engages in their community. Developing strategies as well as empowering yourself and others are key for living well after injury. Though it may feel like a long process, growth and change after brain injury can be possible with patience, flexibility, and when even the small victories are celebrated.

Create structure & keep routines with scheduled breaks

Minimize distractions/clutter and break tasks, goals, or instructions into smaller, realistic ones.
Consistency & a schedule can help with memory and reducing confusion.

Practice creativity and flexibility in rehabilitation

Make opportunities out of every activity or chore into practicing a skill.
Use repetition, rephrasing, and cueing while providing written, accessible handouts.

Connect with resources & people

Prevent any feeling of isolation by linking with supports in the area or online.
Identify what you need with self-care to prevent burnout, fatigue, and frustration.

Educate, then advocate

Educate yourself and others on brain injury to advocate for your needs and services.
Look online for resources, events, education, committees, and more.

Try, adapt, and modify - Every person is different

Use planners, labeling, color-coded systems, notebooks, Smartphone apps, communication books, etc. to help with everyday tasks.
If something doesn't work or fit, brainstorm ways to modify it for the person.
Seek out independent living or employment specialists for assistive technology or tools.

Be proactive in solving problems & plan ahead

Offer or ask for on-the-spot, specific feedback (what do you want vs. do not).
Create plans or develop alternative strategies for escalating mood/behavior.
Investigate behaviors for what they are trying to communicate (a need, safety, or discomfort).

References

Resources

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